Heart transplantation using donation after circulatory death (DCD) has recently re-emerged alongside donation after brain death (DBD). This technique can potentially increase the number of available cardiac grafts. However, its clinical outcomes remain limited. We compared data from patients who received grafts from DCD versus DBD between 2012 and 2023. During this period, 131 adult patients underwent isolated heart transplantation. Of these, 25 (19%) were DCD donors. Donation after circulatory death donors were predominantly local (66% vs . 42%; p = 0.027). Donation after circulatory death graft recipients had fewer ventricular assist devices (12% vs . 35%; p = 0.025) and were less frequently urgent (12% vs . 39%; p = 0.009). Donation after circulatory death grafts had shorter myocardial ischemia and extracorporeal circulation times than DBD grafts (70 min [63.5-91] vs . 168 [83-219]; p < 0.001); (90 min [78-103) vs . 120 [96-148], p < 0.001). We observed no significant differences in the incidence of primary graft failure (16% vs . 22%; p = 0.526) or hospital mortality (8% vs . 14%; p = 0.410) between both groups. In conclusion, cardiac DCD demonstrates hospital outcomes comparable to those of cardiac DBD. Further long-term follow-up of these patients is necessary to determine their rejection, graft vascular disease, and mortality outcomes.

Background: In donation after circulatory death (DCD) heart transplants, choosing an optimal procurement method between normothermic regional perfusion (NRP) and direct procurement and preservation on the TransMedics Organ Care System (OCS) remains an important consideration. Thus, we aimed to evaluate long-term outcomes between NRP and OCS in DCD heart transplants. Methods: Using the UNOS registry, we queried all adults (≥18 years old) undergoing DCD and donation after brain death (DBD) heart transplantation between December 2019 and September 2023. TransMedics OCS donors were defined by time from death to clamp ≤30 minutes. Comparatively, NRP donors were defined by time from death to clamp &gt;30 minutes. Kaplan–Meier recipient and graft survival analyses were conducted. Multivariate Cox proportional hazard models were used to identify independent predictors of mortality. Results: We identified 11,767 DBD transplants, 507 OCS, and 265 NRP recipients. Acute rejection rates were not significantly different between groups (p = 0.42). However, significant differences in overall survival were identified between DBD, OCS, and NRP (p = 0.019). Nonetheless, this difference may be attributed to a significant decline in survival for OCS recipients at 3 years (60.7% vs. 78.8% for DBD vs. 83.3% for NRP). Moreover, there were significant differences in graft survival (p = 0.02), with NRP demonstrating superior outcomes at 3 years (83.3%) compared to 60.7% for OCS and 80.0% for DBD. Conclusion: Both procurement methods demonstrate comparable short-term survival and graft function. However, long-term outcomes are more favorable among NRP recipients than OCS and conventional DBD methods. Nevertheless, continued investigation is needed to understand why this mortality difference exists.

Introduction: Heart transplantation (HT) with donation after circulatory death (DCD) donors has been increasing exponentially since its resurgence in the US. The aim of this study was to evaluate national outcomes of DCD HT. Methods: Adult HT recipients from 2019-2023 were identified from the United Network Organ Sharing registry. Patients were categorized based on donor-type (donation after brain death [DBD] or DCD). Kaplan-Meier and multivariable Cox regression analyses were used for survival. A propensity-matched analysis was also performed. A further sub-analysis was conducted comparing outcomes of DCD HT using normothermic regional perfusion (NRP) versus direct procurement and perfusion (DPP). Results: Among 19,684 HTs identified, 14,122 DBD and 1,139 DCD were included. The number of DCD HT increased from 7 in 2019 to 534 in 2023. In unadjusted analysis, 30-day (97.1% vs 96.7%, p=0.46) and 1-year (91.2% vs 90.5%, p=0.59) survival were comparable between DBD vs. DCD donors, although 3-year survival was worse in DCD recipients (DBD 83.7% vs DCD 76.8%, p=0.05; DCD multivariable HR 1.25, 95% CI 1.02-1.54; p=0.03). Similar findings were observed in the propensity-matched analysis, where DCD recipients had worse 1- and 3-year survival, findings that were confirmed after risk-adjustment (Figure). In sub-analysis comparing NRP versus DPP, unadjusted survival was comparable at all time intervals although there was a trend towards improved survival with NRP at 3-years (NRP 85.7% vs DPP 74.4%, p=0.08; NRP multivariable HR 0.63, 95% CI 0.39-1.02; p=0.06). Conclusions: This represents the largest real-world series to date of DCD HT and associated outcomes. DCD HT has increased substantially in the past several years and now comprises 15% of all HT performed in the United States. Although early outcomes are comparable with DBD donors, mid-term survival was worse by use of DCD, warranting further research. Although not statistically significant, use of NRP technique when using DCD for HT may confer a survival benefit.

BackgroundDonation after circulatory death with thoracoabdominal normothermic regional perfusion (DCD-NRP) for cardiac transplant has promising results, though data for lung transplant is lacking. This study evaluates lung transplant outcomes using DCD-NRP allografts.MethodsAll patients who underwent lung transplantation (LT) from June 1, 2020, to July 5, 2023, at a single institution were evaluated. Recipients received organs from DCD-NRP or brain dead (control) donors (donation after brain death (DBD)). All DCD-NRP were adult, primary bilateral LT (BLT) without preoperative extracorporeal membrane oxygenation (ECMO). Inclusion criteria for controls were age >18 years, BLT, no preoperative ECMO, and primary transplantation. Comparison was separated by LT or heart-lung transplant (HLT). The primary outcome was primary graft dysfunction (PGD) grade 3 at 72 hours.ResultsThere were 8 LT and 3 HLT in the DCD-NRP cohort, and 138 BLT and 7 HL DBD controls. PGD grade 3 at 72 hours was 0% in the entire DCD-NRP cohort (vs control: 9.4% LT and 0% HLT). There were no statistically significant differences in donor and recipient characteristics, though DCD-NRP HLT had significantly shorter ischemic time (85 vs 200 minutes, p < 0.02). Thirty-day and 90-day mortality and 1-year survival are similar in both cohorts for LT and HLT. To date, DCD-NRP recipients are all on room air, with 0% acute cellular rejection rate and 91% (10/11) without chronic rejection. The lung utilization rate of evaluated DCD-NRP donors was 100%.ConclusionsInitial results of LT using DCD-NRP organs demonstrate similar PGD grade 3 at 72 hours and similar survival to standard donors. Donation after circulatory death with thoracoabdominal normothermic regional perfusion (DCD-NRP) for cardiac transplant has promising results, though data for lung transplant is lacking. This study evaluates lung transplant outcomes using DCD-NRP allografts. All patients who underwent lung transplantation (LT) from June 1, 2020, to July 5, 2023, at a single institution were evaluated. Recipients received organs from DCD-NRP or brain dead (control) donors (donation after brain death (DBD)). All DCD-NRP were adult, primary bilateral LT (BLT) without preoperative extracorporeal membrane oxygenation (ECMO). Inclusion criteria for controls were age >18 years, BLT, no preoperative ECMO, and primary transplantation. Comparison was separated by LT or heart-lung transplant (HLT). The primary outcome was primary graft dysfunction (PGD) grade 3 at 72 hours. There were 8 LT and 3 HLT in the DCD-NRP cohort, and 138 BLT and 7 HL DBD controls. PGD grade 3 at 72 hours was 0% in the entire DCD-NRP cohort (vs control: 9.4% LT and 0% HLT). There were no statistically significant differences in donor and recipient characteristics, though DCD-NRP HLT had significantly shorter ischemic time (85 vs 200 minutes, p < 0.02). Thirty-day and 90-day mortality and 1-year survival are similar in both cohorts for LT and HLT. To date, DCD-NRP recipients are all on room air, with 0% acute cellular rejection rate and 91% (10/11) without chronic rejection. The lung utilization rate of evaluated DCD-NRP donors was 100%. Initial results of LT using DCD-NRP organs demonstrate similar PGD grade 3 at 72 hours and similar survival to standard donors.

OBJECTIVE: This study compares the incidence of severe Primary Graft Dysfunction (PGD) in a contemporaneous cohort of donors after circulatory death (DCD) and brain death (DBD) heart transplant recipients. METHOD: The United Network for Organ Sharing database was queried for isolated adult heart transplant recipients from 9/2023 to 6/2024. Heart recipients were stratified based on the organ donation type (DCD vs DBD). DCD heart recipients were further categorized based on the procurement method: time between circulatory death to cross-clamp: ≤ 30 minutes (Direct Procurement and Preservation, DPP), >30 minutes (Normothermic Regional Perfusion, NRP). Outcomes of interest included: severe PGD (Left/Bi-Ventricular; LV/BiV) at 24 hours and Severe Graft Dysfunction at 72 hours (patients with severe PGD at 24 hours that remain on mechanical support at 72 hours). RESULTS: A total of 2590 adult heart transplant recipients were identified, of which 17.1% underwent DCD heart transplantation. DCD heart recipients were less likely to be on inotrope (36.7% vs 41.6%, p=0.046) and ECMO (4.1% vs 9.9%, p<0.001) prior to transplant than DBD heart recipients. DCD heart recipients were more likely than DBD heart recipients to develop severe PGD (LV/BiV) at 24 hours (9.5% vs 5.1%, p<0.001). The Severe Graft Dysfunction at 72 hours (2.3% vs 2.9%, p=0.67) and 30-day mortality were similar between the 2 groups. Recipients of DCD heart procured with DPP or NRP had similar severe PGD (LV/BiV) at 24 hours (9.4% vs 9.7%, p=0.93). CONCLUSION: Severe PGD at 24 hours is higher among the DCD than DBD heart recipients, but Graft Dysfunction improves by 72 hours.

Heart transplantation (HTx) is greatly limited by organ shortage. To address this crisis, donation after circulatory death (DCD) is an emerging alternative to the traditional donation after brain death (DBD). Unfortunately, there is scarce data on HTx outcomes for this donation type, particularly within the United States; our investigation seeks to address this knowledge gap. As part of this study, the UNOS thoracic database was analyzed for first-time, adult, isolated orthotopic HTx recipients between 2019 and 2023. Patients were stratified into 3 groups: DBD, DCD III, and DCD IV. Further subgroup analysis for DCD III donors was conducted based on the procurement method, direct procurement and perfusion (DPP) or normothermic regional perfusion (NRP). After creating the sample cohort, a total of 14,035 HTx recipients were included in our analysis (DBD 86.5%, DCD III 6.9%, DCD IV 6.5%). There was an exponential increase in the number of DCD III cases and HTx centers that offer this donation type during the study period. DCD III recipients had a higher incidence of postoperative dialysis use; otherwise, all 3 groups shared similar rates of postoperative permanent pacemaker placement and stroke, acute rejection, and mortality. Within DCD III recipients, DPP and NRP procurement techniques had similar survival. To conclude, although DCD III was associated with an increased incidence of postoperative dialysis use, both DCD type III and IV had comparable morbidity and survival as the standard of care DBD donors. Overall, our investigation provides encouraging data to support DCD use as a safe option to increase the limited donor pool in the United States.

BackgroundHeart transplantation is an effective treatment offering the best recovery in both quality and quantity of life in those affected by refractory, severe heart failure. However, transplantation is limited by donor organ availability. The reintroduction of heart donation after the circulatory determination of death (DCD) in 2014 offered an uplift in transplant activity by 30%. Thoraco-abdominal normothermic regional perfusion (taNRP) enables in-situ reperfusion of the DCD heart. The objective of this paper is to assess the clinical outcomes of DCD donor hearts recovered and transplanted from donors undergoing taNRP.MethodThis was a multicentre retrospective observational study. Outcomes included functional warm ischaemic time, use of mechanical support immediately following transplantation, perioperative and long-term actuarial survival and incidence of acute rejection requiring treatment. 157 taNRP DCD heart transplants, performed between February 2, 2015, and July 29, 2022, have been included from 15 major transplant centres worldwide including the UK, Spain, the USA and Belgium. 673 donations after the neurological determination of death (DBD) heart transplantations from the same centres were used as a comparison group for survival.FindingstaNRP resulted in a 23% increase in heart transplantation activity. Survival was similar in the taNRP group when compared to DBD. 30-day survival was 96.8% ([92.5%–98.6%] 95% CI, n = 156), 1-year survival was 93.2% ([87.7%–96.3%] 95% CI, n = 72) and 5-year survival was 84.3% ([69.6%–92.2%] 95% CI, n = 13).InterpretationOur study suggests that taNRP provides a significant boost to heart transplantation activity. The survival rates of taNRP are comparable to those obtained for DBD transplantation in this study. The similar survival may in part be related to a short warm ischaemic time or through a possible selection bias of younger donors, this being an uncontrolled observational study. Therefore, our study suggests that taNRP offers an effective method of organ preservation and procurement. This early success of the technique warrants further investigation and use.FundingNone of the authors have a financial relationship with a commercial entity that has an interest in the subject.

(1) Background: Cardiac donation after circulatory death (DCD) is an emerging paradigm in organ transplantation. However, this technique is recent and has only been implemented by highly experienced centers. This study compares the characteristics and outcomes of thoraco-abdominal normothermic regional perfusion (TANRP) and static cold-storage DCD and traditional donation after brain death (DBD) cardiac transplants (CT) in a newly stablished transplant program with restricted donor availability. (2) Method: We performed a retrospective, single-center study of all adult patients who underwent a CT between November 2019 and December 2023, with a follow-up conducted until August 2024. Data were retrieved from medical records. A review of the current literature on DCD CT was conducted to provide a broader context for our findings. The primary outcome was survival at 6 months after transplantation. (3) Results: During the study period, 76 adults (median age 56 years [IQR: 50–63 years]) underwent CT, and 12 (16%) were DCD donors. DCD donors had a similar age (46 vs. 47 years, p = 0.727), were mostly male (92%), and one patient had left ventricular dysfunction during the intraoperative DCD process. There were no significant differences in recipients’ characteristics. Survival was similar in the DCD group compared to DBD at 6 months (100 vs. 94%) and 12 months post-CT survival (92% vs. 94%), p = 0.82. There was no primary graft dysfunction in the DCD group (9% in DBD, p = 0.581). The median total hospital stay was longer in the DCD group (46 vs. 21 days, p = 0.021). An increase of 150% in transplantation activity due to DCD was estimated. (4) Conclusions: In a new CT program that utilized older donors and included recipients with similar illnesses and comorbidities, comparable outcomes between DCD and DBD hearts were observed. DCD was rapidly incorporated into the transplant activity, demonstrating an expedited learning curve and significantly increasing the availability of donor hearts.

INTRODUCTION: Thoracoabdominal normothermic regional perfusion (TA-NRP) following cardiac death is an emerging multivisceral organ procurement technique. Recent national studies on outcomes of presumptive TA-NRP-procured organs are limited by potential misclassification since TA-NRP is not differentiated from donation after cardiac death (DCD) in registry data. METHODS: We studied 22 donors whose designees consented to TA-NRP and organ procurement performed at our institution between January 20, 2020 and July 3, 2022. We identified these donors in SRTR to describe organ utilization and recipient outcomes and compared them to recipients of traditional DCD (tDCD) and donation after brain death (DBD) organs during the same timeframe. RESULTS: All 22 donors progressed to cardiac arrest and underwent TA-NRP followed by heart, lung, kidney, and/or liver procurement. Median donor age was 41 years, 55% had anoxic brain injury, 45% were hypertensive, 0% were diabetic, and median kidney donor profile index was 40%. TA-NRP utilization was high across all organ types (88%-100%), with a higher percentage of kidneys procured via TA-NRP compared to tDCD (88% vs. 72%, p = .02). Recipient and graft survival ranged from 89% to 100% and were comparable to tDCD and DBD recipients (p ≥ .2). Delayed graft function was lower for kidneys procured from TA-NRP compared to tDCD donors (27% vs. 44%, p = .045). CONCLUSION: Procurement from TA-NRP donors yielded high organ utilization, with outcomes comparable to tDCD and DBD recipients across organ types. Further large-scale study of TA-NRP donors, facilitated by its capture in the national registry, will be critical to fully understand its impact as an organ procurement technique.

BACKGROUND: Recovery of hearts from donation after circulatory death donors has been performed either with direct procurement and perfusion (DPP) using the TransMedics Organ Care System or with normothermic regional perfusion (NRP) with subsequent cold storage. It remains unclear which of these 2 strategies yields optimal posttransplant outcomes. METHODS: All heart transplant recipients from donors after circulatory death donors at the Vanderbilt University Medical Center (Nashville, TN) were reviewed (February 2020 to January 2023). Recipients were stratified into an NRP or DPP cohort. All DPP recoveries were performed using the TransMedics Organ Care System. The key outcome was severe primary graft dysfunction at 24 hours, defined by the need for postoperative extracorporeal membrane oxygenation. RESULTS: A total of 118 hearts were transplanted (NRP, 87; DPP, 31). Donors recovered using NRP were younger (25 years [interquartile range {IQR}, 21-31 years] vs 31 years [IQR, 24-37 years]; P = .008) and had shorter distance traveled (292 miles [158-516 miles] vs 449 miles [IQR, 248-635 miles]; P = .02). Recipient preoperative risk factors were similar between the groups. There was no difference in the incidence of severe primary graft dysfunction at 24 hours (NRP, 5.8%; and DPP, 12.9%; P = .24). However, ejection fraction at 7 days after transplantation was higher in the NRP group (65% [IQR, 60%-65%] vs 60% [IQR, 60%-68%]; P = .005). There was no difference in inotrope scores at 24 hours (P = 1.00) or 72 hours (P = .87) or in 30-day (NRP, 95% vs DPP, 97%; P = .75) and 1-year (NRP, 94% vs DPP, 86%; P = .19) survival. CONCLUSIONS: NRP and DPP strategies for recovery of cardiac allografts yield comparable early allograft outcomes. Future studies are needed to confirm these findings in larger prospective cohorts.